Abdullar, S

Borghi, J

Ipuge, Y

John , P

Mamdani, M

Mashasi, I

Mayumana, I

Njau, I

Olafsdottir, A

Patouillard, E

English

Digital Library of the Tanzania Health Community

Factors affecting P4P implementation. Qualitative interviews
revealed that P4P bonuses were a motivating factor for health
workers in the context of health workers’ dissatisfaction with their
pay (Figure 1), notably at dispensary and health centre levels.
“P4P helps [workers] to get some money and this motivates them to 
provide services more efficiently”, District manager
“ P4P payment motivates me to work [...]” Health worker.
There were however important concerns regarding the potential
for P4P to create tensions between RCH/non-RCH staff at
hospital level due to the differential bonus amount ($30 vs. $4
respectively).
P4P targets were also perceived to be too difficult to attain due
to current system constraints.
“They want us to implement P4P but they did not consider the 
weaknesses in the system” District Manager. 
The main constraint included medical supply and drug
shortages, and the lack of medically trained staff (Table 3).
“The shortage of drugs, this makes us fail…many drugs were not 
available; malaria pills [IPT] were not available and it is one of the P4P 
indicators”  Health Worker 
“Because of the shortage of  [medically trained staff] you can hold a 
newborn while the mother continues to bleed [...] you don’t know who to 
save [...]  this situation is totally demoralising” Health Worker
Results
Household survey baseline data show relatively high coverage of
MCH services in P4P’s facility catchment areas, notably for
institutional deliveries. Postnatal care (PNC) coverage was
however relatively low (Table 1).
Title Verdana 
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improving health worldwide www.lshtm.ac.uk
Evaluation of a pay for performance scheme in Tanzania
Patouillard E1,2, Mamdani M2, John P2, Mashasi I2, Mayumana I2, Njau I2, 
Ipuge Y 2, Olafsdottir A 2,Abdulla S2 andBorghi J1,2 
1 London School of Hygiene & Tropical Medicine, London, UK
2 Ifakara Health Institute, Dar es Salaam, Tanzania
Introduction
A Pay for Performance (P4P) scheme of 6-monthly results-based
bonuses to health workers, their facilities and district/regional
managers who achieve pre-defined performance targets for
maternal and child health (MCH) services is being piloted in one
region of Tanzania. All MCH 7 Hospitals, 17 Heath Centres and
182 Dispensaries can participate. Bonuses amount of $30 to
health workers - ~10% of average monthly salary ($4 to non-
MCH hospital workers) and $25 to managers. We present data
on MCH service use at baseline, facility performance at the first
payment cycle (Cycle 1) and P4P implementation process during
the first 16 months of the pilot.
Methods
A non-randomised controlled before-after study was designed to
measure the impact of P4P on the use, cost and quality of
targeted and non-targeted services. Interviews during the
baseline surveys were conducted with 3,000 households of
women who gave birth in the past year; 1,500 patients following
a consultation at a health facility; 200 health workers; and 150
health facilities. A qualitative study was also designed to collect
information on the implementation process of the P4P pilot and
its acceptability and sustainability through document review and
60 qualitative interviews with key stakeholders.
Conclusions
P4P is a welcome initiative with the potential to boost health workers’ motivation, notably at lower levels of care. However, systemic
constraints are perceived to impede implementation. Bonuses allocated to health facilities are expected to be used for addressing such
constraints. Continuous process implementation research will provide evidence on how bonus payments are used by facilities to address
such constraints whilst endline survey data will reveal P4P impact on targeted and non-targeted service use, cost and quality.
Baseline
household 
data 
Women with ≥ 
4 ANC visits
ANC by 
doctor
(nurse)
Delivered at 
facility (public)
Delivery by 
medical staff 
(TBA)
PNC ≤ 
2months 
after birth
% of women 66 12 (88) 85 (77) 86 (14) 32
Table 1:Coverage of MCH services in the pilot region at baseline
Source: P4P baseline household survey
Facility performance and bonuses. Cycle 1 overall
performance was low, except for vaccination targets of infants
under one year (U1) (Table 2).
Figure 1 – Health Workers’ Satisfaction
Source: P4P baseline health worker survey
0
1
2
3
Supervisor’s 
recognition
Discuss issues with 
supervisors 
Availability of 
medicines
Availability of 
equipments
Availability of 
supplies
Employment benefits
Salary
Opportunities for 
promotion
Table 2: Performance indicators and facility target achievements
Source: P4P Project Management Team Cycle 1 performance report
P4P Performance Indicators
Cycle 1
% facilities that achieve 
100% of performance 
target
Full bonus received
% facilities that 
achieve 75-99% of  
performance target
Half bonus
% facilities that 
achieve <75% of 
performance target
No bonus
% of ANC clients receiving IPT2 
(malaria prophylaxis)
8 5 87
% of HIV+ ANC clients receiving 
ARVs
19 4 76
% of newborns receiving oral polio 
vaccine ≤2 weeks after birth
24 16 60
% of U1 receiving measles vaccine 45 22 32
% of U1 receiving pentavalent 3 
vaccine
44 24 33
% of institutional deliveries 27 16 57
Resource Availability 
at facility
% facilities that report 
resource availability*
% facilities that report stock 
out / absence**
(mean no of days)
IPT drugs 83 19 (54)
Oral polio vaccine 98 15(24)
Measles vaccine 98 9 (25)
Medical officer 14 30 (n/a)
Clinical officer 46 35
Nurse midwives 41 17
*for drugs, availability at time of interview; for staff, at least one staff employed at facility; **for drugs, stock outs in 
past 90 days; for staff ,absence at least one day in past 30 days.
Table 3: Facility resources at baseline 
Source: P4P baseline health facility survey 
Presented at the workshop "Measuring Intervention Intensity in Evaluation Studies" organised by the Centre for Evaluation at the LSHTM. The evaluation study is a collaboration between the Ifakara Health 
Institute in Tanzania and the LSHTM, with financial support from the Government of Norway and technical support from Chr. Michelsen Institute in Norway.

Evaluation of a pay for performance scheme in Tanzania

http://ihi.eprints.org/849/1/P4P_Evaluation_Poster_Final.pdf

Evaluation of a pay for performance scheme in Tanzania

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